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The association of resistance trainingwith mortality: A systematic reviewand meta-analysis

Farzane Saeidifard1, Jose R Medina-Inojosa1, Colin P West2,3,Thomas P Olson1, Virend K Somers1, Amanda R Bonikowske1,Larry J Prokop4, Manlio Vinciguerra5 andFrancisco Lopez-Jimenez1

Abstract

Background: The benefits of aerobic exercise are well-studied; there is no consensus on the association between

resistance training and major adverse cardiovascular outcomes. This systematic review and meta-analysis aimed to

address this issue.

Design and methods: We searched for randomized trials and cohort studies that evaluated the association between

resistance training and mortality and cardiovascular events. Two investigators screened the identified abstracts and full-

texts independently and in duplicate. Cochrane tools were used to assess the risk of bias. We calculated hazard ratios

and 95% confidence intervals using random effect models.

Results: From the 1430 studies identified, 11 (one randomized trial and 10 cohort studies) met the inclusion criteria,

totaling 370,256 participants with mean follow-up of 8.85 years. The meta-analysis showed that, compared with no

exercise, resistance training was associated with 21% (hazard ratio (95% confidence interval (CI)), 0.79 (0.69–0.91)) and

40% (hazard ratio (95% CI), 0.60 (0.49–0.72)) lower all-cause mortality alone and when combined with aerobic exercise,

respectively. Furthermore, resistance training had a borderline association with lower cardiovascular mortality (hazard

ratio (95% CI), 0.83 (0.67–1.03)). In addition, resistance training showed no significant association with cancer mortality.

Risk of bias was low to intermediate in the included studies. One cohort study looked at the effect of resistance training

on coronary heart disease events in men and found a 23% risk reduction (risk ratio, 0.77, CI: 0.61–0.98).

Conclusion: Resistance training is associated with lower mortality and appears to have an additive effect when

combined with aerobic exercise. There are insufficient data to determine the potential beneficial effect of resistance

training on non-fatal events or the effect of substituting aerobic exercise with resistance training.

Keywords

Resistance training, strength training, mortality, cardiovascular outcome, systematic review, meta-analysis

Received 5 February 2019; accepted 23 April 2019

Introduction

Sedentary lifestyle is a risk factor for a shorter lifespan,adverse cardiovascular events and many other comor-bidities such as diabetes, hypertension, obesity andcancer.1,2 A range of physical activities, from standingand walking to performing moderate-to-vigorous phys-ical activities, reduce sedentary time and have beenindependently associated with longer life expectancyand improvement in quality-of-life,3 with lower ratesof multiple comorbidities and mortality.3–5 Physical

1Division of Preventive Cardiology, Department of Cardiovascular

Medicine, Mayo Clinic Rochester, USA2Division of General Internal Medicine, Mayo Clinic, Rochester, USA3Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester,

USA4Mayo Clinic Libraries, Mayo Clinic, Rochester, USA5International Clinical Research Center (ICRC), St. Anne’s University

Hospital, Brno, Czech Republic

Corresponding author:

Francisco Lopez-Jimenez, Division of Preventive Cardiology, Department

of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester,

MN 55905, USA.

Email: [email protected].

European Journal of Preventive

Cardiology

0(00) 1–19

! The European Society of

Cardiology 2019

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activity including endurance and resistance training mayalso improve clinical outcomes even in patients with car-diovascular or valvular heart disease.6,7 Most of the evi-dence for the benefits of substituting sedentary time withphysical activity has focused on testing the effect of aer-obic exercise on different health measures.8 Existing evi-dence overwhelmingly shows that aerobic exercisepositively affects health measures including increasinglifespan, reducing rates of cardiovascular events,improving metabolic health, and preventing manycomorbidities, while lowering healthcare costs.9,10

Another form of physical activity that can be used toreduce sedentary time is resistance training; however,whether resistance training shares the potential benefitsand positive long-term effects of aerobic exercise onhealth in general, and on cardiovascular events inparticular, is currently unclear. Resistance training nor-mally involves lifting weights (using either machines orfree weights) typically at loads greater than 65% of theone-repetition maximum, defined as the heaviest weighta person can lift with maximum effort in a single repe-tition.11 Resistance training is sub-divided into dynamicresistance training, involving concentric and/or eccen-tric contractions of muscles with changes in length andthe tension of the muscles, and static exertion or iso-metric resistance training, based on sustained musclecontraction against a fixed load or resistance with nochange in length of the muscles.12 Mechanistic studieshave shown that relatively short periods of resistancetraining could lead to improvements in a number ofcardiovascular risk factors including insulin resistance,glucose and lipid metabolism,5,11 and endothelial func-tion, with reduced sympathetic neural activation.13

Further, a small number of epidemiologic studies sug-gest a possible beneficial effect on survival,14–16 but theresults have been conflicting and inconclusive.

The present study aims to systematically review theassociation between resistance training and multipleoutcomes including all-cause mortality, cardiovascularmortality, cancer mortality, ischemic heart disease, andstroke, with a focus on comparisons between resistancetraining and no resistance training adjusted for aerobicexercise, and resistance training versus aerobic exercise.

Methods

We designed the protocol based on the CochraneHandbook of Systematic Reviews of Intervention andPreferred Reporting Items for Systematic Reviews andMeta-Analysis (PRISMA) statement, and the ScientificStatement from the American Heart Association onsystematic review and meta-analysis on cardiac preven-tion and treatment studies.17

We searched for randomized or quasi-randomizedtrials and cohort studies that compared resistance

training with aerobic exercise or no exercise, in the gen-eral adult population in terms of major cardiovascularoutcomes including all-cause mortality, cardiovascularmortality, cancer mortality, ischemic heart disease, andstroke. We did not exclude studies on the basis of theyear of publication, language, or length of follow-up;but we excluded studies with different designs oroutcomes.

We conducted a comprehensive search of severaldatabases from each database’s inception to 25September 2017. The databases included OvidMEDLINE Epub Ahead of Print, Ovid Medline In-Process & Other Non-Indexed Citations, OvidMEDLINE, Ovid EMBASE, Ovid Cochrane CentralRegister of Controlled Trials, Ovid CochraneDatabase of Systematic Reviews, and Scopus. Thesearch strategy was designed and conducted by anexperienced librarian (LJP) with input from thestudy’s lead investigators. We used controlled vocabu-lary supplemented with keywords to search for theassociation between resistance training and cardiovas-cular outcomes in adults (detailed strategy is availablein the Supplementary Material online). We renewed thesearch on 6 November 2018.

One investigator (FS) reviewed the references of theeligible studies to identify any additional studies thathad been missed by the original search. Additionally,the authors of the eligible studies were contacted byemail to identify any similar studies done by the sameauthor or other authors that were not found in theprimary search.

Having applied the search strategy and generated alist of potential studies, two investigators (FS andJRMI) conducted eligibility screening: first, by exclud-ing any papers that did not match the criteria of interestbased on the title and abstracts; and second, by review-ing their full text to evaluate their eligibility for inclu-sion in the final analysis. The entire screening processwas performed independently and in duplicate using thesystematic review software Covidence�.

Studies meeting all eligibility criteria underwent dataextraction for further analysis. When the investigatorsdisagreed on the inclusion or exclusion of a study, theywould discuss the case and attempt to resolve the issue;when a third opinion was needed the senior investigator(FLJ) would independently review the study and makea final decision.

The data abstraction included the general character-istics of the study (author, year of publication, studydesign), characteristics of the study participants(sample size, age, gender, and basic health status inboth intervention and control groups), characteristicsof the intervention and comparisons (type, frequency,and intensity of resistance training) and the duration offollow-up, and outcomes data (all-cause mortality,

2 European Journal of Preventive Cardiology 0(00)

cardiovascular mortality, cancer mortality, ischemicheart disease, and stroke). Data were collected by twoinvestigators (FS and JRMI) independently and induplicate. The authors of studies were contacted whenthe data needed in the analysis were not accessiblethrough the published version of the articles.

We used Cochrane tools for assessment of the risk ofbias in clinical trials and observational studies at bothstudy and outcome levels. The tool used for the clinicaltrials assessed the sequence generation, allocationconcealment, blinding, incomplete outcome data, andselective outcome reporting, and other sources of bias.The tool for evaluation of the observational studies(ROBINS-E) assessed different domains for any pos-sible bias.18,19 The domains for evaluating the risk ofbias are as follows: confounding bias, bias in selectionof the participants into the study, bias in classificationof exposures, bias due to departures from intendedexposures, bias due to missing data, bias in measure-ment of outcomes, bias in selection of the reportedresult, and overall risk of bias.

Since most of the included studies were derived fromNational Health and Nutritional Examination Survey(NHANES) and National Health Interview Survey(NHIS) surveys, we minimized the overlap between par-ticipants of the included papers in several ways. Toexclude the studies with overlap but not losing anyimportant data, we contacted the authors of the originalstudies, looking for data on specific subgroup analyses.We excluded studies that were conducted in the sametime frame and also those that had more than 10% over-lap in their study samples. Finally, when conductingsubgroup analyses we verified that no subgroups repre-senting the same population would be included.

The outcomes-of-interest in this study were countsand rates and reported mostly as hazard ratio or riskratio (RR) (from Cox regression model) and in onestudy as odds ratio (OR) (from logistic regressionmodel); we converted OR to RR ((RR¼OR/(1-preva-lence of the outcome in the reference group)þ (preva-lence of the outcome in the reference group)) andassumed the RR equivalent to hazard ratio for the ana-lysis. For analyses adjusted for covariates we used themost adjusted ratios, recognizing that those analyseswould adjust for similar but not identical potential con-founders. The majority of the multivariate analysesincluded for covariates age, gender, comorbidities(including hypertension, hyperlipidemia, and diabetesmellitus), body mass index, physical activities, aerobicexercise, smoking status, and diet.

To conduct a meta-analysis we used RevMan v.5.3and generic inverse variance model. To measure theheterogeneity between the individual studies for eachoutcome we used I2 statistics, deeming I2 values morethan 75% as considerable heterogeneity. Funnel plots

were used and visually inspected for assessing publica-tion bias.

We predefined different subgroup analyses based onfactors believed to affect the possible associationbetween resistance training and outcomes, such as:intensity, frequency (low: >2, moderate: 2–5 and high�5 sessions/week) and duration of the resistance train-ing, gender, presence or absence of hypertension, base-line health status of the participants, and patient orpopulation based studies. We also predefined a sub-group based on the level of adjustment of the analysiscomparing resistance training with the primary out-comes, dividing studies adjusted for multiple potentialconfounders versus those adjusted only for age and/orgender, or not adjusted.

Results

The primary search identified 1421 records and ninemore studies were found by searching the referencelists of the eligible studies. From these records, 11 studieswith a total of 370,256 participants met the inclusioncriteria for the systematic review and meta-analysis,from which eight were from the screening of the studiesidentified through the primary search and three werefrom those identified through hand-searching. Figure 1is a PRISMA diagram showing the details of each stageof the screening and eligibility assessment and also thereasons for the exclusion of the studies. Reviewers werein agreement over which studies should be included(j¼ 0.83).

Although the primary search included key termsfor major cardiovascular outcomes, the majority ofthe studies included in the final analysis assessed onlymortality (all-cause, cardiovascular, and cancer).

Table 1 shows the characteristics of the stu-dies14–16,20–27 in detail. One study was a randomizedclinical trial and the other studies were cohort studies,mostly focused on the data from the NHANES andNHIS. All of the studies except one were done in theUnited States. All of the included studies were pub-lished in English and one of the studies was not yetpublished by the time of the data extraction so itsdata were obtained through contacting the authors.20

The average follow-up was 8.85 years and the agerange was 18–75 years. Within-study risk of bias waslow to moderate (we considered a mild risk of bias forthe design of the included studies, which were mostlycohorts compared with a well-done randomized clinicaltrial) in all of the included studies, except one that wasmoderate. Table 2 shows the details of the risk of biasin different domains for each study.

The studies evaluating the association betweenresistance training and all-cause mortality included341,820 participants. The results are presented in

Saeidifard et al. 3

Figures 2–4: Figure 2(a) shows that performing anyfrequency of resistance training is associated with21% lower all-cause mortality in comparison with noexercise (hazard ratio (95% confidence interval (CI)),0.79 (0.69–0.91)). Based on the subgroup analysis, per-forming >0 to two sessions of resistance training perweek is associated with lower all-cause mortality (0.79(0.66–0.95)), but doing more than two sessions of resist-ance training is not (Figure 2(b)). These results wereunchanged after performing a sensitivity analysis thatrestricted the analysis to population based studies (datanot shown). Additionally, the results show that follow-ing the current recommendations by the AmericanCollege of Sport Medicine and the American HeartAssociation on performing 2–3 sessions of resistancetraining per week is not significantly better than per-forming lower frequencies of resistance training interms of all-cause mortality (1.00 (0.89–1.11)) (Figure2(c)).

Some studies included in this analysis also comparedaerobic exercise with no exercise21–24 and, as expected,they demonstrated that aerobic exercise is associatedwith lower all-cause mortality (0.59 (0.45–0.76) forany aerobic exercise versus no exercise21–24) with adose–response relationship (data not shown) (0.64(0.56–0.74) for 1–2 sessions of aerobic exercise22–24

and 0.56 (0.41–0.76) for� 2 sessions of aerobicexercise21–24).

Some studies tested the association between thecombination of resistance training and aerobic exerciseand all-cause mortality. As Figure 2(d) shows, the

combination of any frequency of resistance trainingwith any frequency of aerobic exercise compared withno exercise is associated with a significantly lower all-cause mortality (40%, 0.60 (0.49–0.72)).

The association between resistance training and car-diovascular mortality was tested in 122,671 participantsand revealed that performing resistance training had aborderline association with lower cardiovascular mor-tality (hazard ratio 0.83 (0.68–1.01)) (Figure 3(a)). Asshown in Figure 3(b) and (c), results suggested that nofrequency of resistance training has a significant asso-ciation with lower cardiovascular mortality. In con-trast, as Figure 3(d) shows, the combination of anyfrequency of resistance training with any frequency ofaerobic exercise compared with no exercise is signifi-cantly associated with lower cardiovascular mortality(0.43 (0.27–0.70)).

The result of the analysis of the data from 57,557participants testing the association between resistancetraining and cancer mortality shows no associationbetween resistance training and cancer mortality (0.81(0.54–1.20)) (Figure 4(a)), which was not affected byincreasing the frequency of resistance training in aweek (Figure 4(b)). Furthermore, the combination ofresistance training and aerobic exercise had no signifi-cant association with cancer mortality (Figure 4(c)).

We identified only one cohort study that investigatedthe association between resistance training and differenttypes of non-fatal events. The study followed 44,452 USmen for two years and defined coronary events as theoccurrence of fatal coronary heart disease and non-fatal myocardial infarctions (MIs). The results of thestudy showed a 23% (RR 0.77, CI: 0.61–0.98) riskreduction in men who trained with weights for 30minor more per week compared with men who did not trainwith weights.28 Two other cohort studies investigatedthe association between resistance training and all fataland non-fatal cardiovascular outcomes under a generaldefinition of ‘‘cardiovascular disease (CVD)’’ and didnot meet our inclusion criteria for the final analysisalthough they reported an association between resist-ance training and lower CVD.29

No study specifically assessed the associationbetween resistance training and cerebrovascularoutcomes.

Discussion

This study showed that performing resistance trainingis associated with lower all-cause mortality while it hasa borderline association with cardiovascular mortality.There is an additional lowering of risk seen amongthose performing resistance training along with aerobicexercise. By contrast, there is no association betweenresistance training and cancer mortality. Based on the

1421 studies identified throughdatabase searching

Nine additional studies identifiedthrough other sources

1430 studies after duplicates removed

27 studies screened Records excluded (n = 5)

for outcomes unrelated to the meta-analysis

22 of full-text articlesassessed for eligibility

11 of studies included in qualitative synthesis

Full-text articles excluded (n = 11)

due to study design

11 of studies included in quantitative synthesis

(meta-analysis)

1423 studies excluded

based on title and abstract

Iden

tific

atio

nS

cree

ning

Elig

ibili

tyIn

clud

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Figure 1. PRISMA flow diagram detailing the literature search,

with the number of included and excluded studies and reasons

for exclusion in each stage.


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Saeidifard et al. 5

Tab

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les,

such

aslif

ting

weig

ht,

push

-ups

or

sit-

ups?

’’;an

dif

so‘‘O

ver

the

pas

t30

day

s,how

man

y

tim

es

did

you

do

these

activi

ties

desi

gned

tost

rengt

hen

your

musc

les,

such

aslif

ting

weig

hts

,push

-ups

or

sit-

ups?

’’as

the

num

ber

ofse

lf-re

port

ed

sess

ions

com

ple

ted

within

the

pas

t30

day

s

Co

mp

ari

son

:not

meeting

the

guid

elin

efo

rm

usc

le

stre

ngt

henin

gac

tivi

ties

Age

,se

x,ra

ce/e

thnic

ity,

edu-

cational

,m

arri

ed,ci

gare

tte

smokin

g,in

tera

ctio

n

betw

een

curr

ent

em

plo

y-

ment

and

follo

w-u

ptim

e,

need

speci

alequip

ment

to

wal

k,ar

thri

tis,

cance

r,

body

mas

sin

dex,in

ter-

action

betw

een

body

mas

s

index

cate

gori

es

and

follo

w-u

ptim

e,

hypert

en-

sion

pre

hypert

ensi

on,an

d

dia

bete

s,pre

dia

bete

s,

oth

er

PA/s

edenta

rybehav

-

ior

com

ponents

.

The

United

Stat

es

(continued)


Tab

le1.

Continued

Firs

t

auth

or

Year

of

public

atio

n

Study

desi

gnN

Mean

follo

w-u

p

(year

s)

Sett

ing

(PIC

O)

(pat

ient,

inte

rvention/e

xposu

re,

com

par

ison,outc

om

e)

Fact

ors

adju

sted

for

Loca

tion

of

the

study

Ou

tco

mes:

all-ca

use

and

card

iova

scula

rm

ort

ality

adju

sted

for

age,

sex,ra

ce/e

thnic

ity,

educa

tional

leve

l,m

arital

stat

us,

smokin

gst

atus,

em

plo

yment,

the

need

for

speci

al

equip

ment

tow

alk,ar

thri

tis,

and

cance

r

Exclu

sio

n:Lim

ited

the

sam

ple

topar

tici

pan

tsw

ho

wer

e40

year

sofag

eor

old

eran

dex

cluded

per

sons

who

wer

enot

elig

ible

for

mort

ality

linka

ge.Par

tici

pan

tsw

ere

aske

d

whet

her

adoct

or

or

hea

lth

pro

fess

ional

ever

told

them

that

they

had

ahis

tory

of

angi

na,

coro

nar

yhea

rtdis

ease

,

conge

stiv

ehea

rtfa

ilure

,m

yoca

rdia

lin

farc

tion,or

stro

ke.

Par

tici

pan

tsw

ere

clas

sifie

das

hav

ing

pre

vale

nt

CV

Dif

they

answ

ered

‘‘yes’

’to

any

of

thes

efiv

eques

tions

and

wer

efu

rther

excl

uded

,al

though

inse

nsi

tivi

tyan

alys

es

thes

epar

tici

pan

tsw

ere

inco

rpora

ted.To

acco

unt

for

pre

vale

nt

conditio

ns

that

mig

ht

affe

ctPA

leve

lsan

dse

d-

enta

rybeh

avio

r,th

eyex

cluded

par

tici

pan

tsw

ho

die

din

the

first

two

year

soffo

llow

-up.

They

also

excl

uded

those

who

eith

erdid

not

wea

rth

eac

cele

rom

eter

or

whose

acce

lero

met

erw

asfo

und

tonot

be

inca

libra

tion

upon

retu

rnor

was

faulty.

Furt

her

limited

the

cohort

by

excl

udin

gper

sons

who

did

not

pro

vide

adher

ent

dat

a.

Las

tly,

excl

uded

those

who

wer

em

issi

ng

dat

aon

self-

report

edPA

or

any

pote

ntial

confo

under

left

inth

efin

al

model

s.

Grø

ntv

ed

25

2012

Cohort

32,0

02

18

Part

icip

an

ts:m

en

from

the

Heal

th

Pro

fess

ional

sFo

llow

-up

Study

Exp

osu

re:m

usc

le-s

trengt

henin

gac

tivi

ties

atbas

elin

e.T

he

par

tici

pan

tsre

port

ed

their

avera

gew

eekly

amount

of

weig

ht

trai

nin

g,oth

er

phys

ical

activi

ties

Co

mp

ari

son

:not

meeting

the

guid

elin

efo

rm

usc

le

stre

ngt

henin

gac

tivi

ties

Ou

tco

mes:

risk

of

type

2dia

bete

s,al

l-ca

use

and

card

io-

vasc

ula

rm

ort

ality

adju

sted

for

age,sm

okin

g,al

cohol

consu

mption,co

ffee

inta

ke,ra

ce,

fam

ilyhis

tory

of

dia

-

bete

s,in

take

of

tota

lenerg

y,tr

ans

fat,

poly

unsa

tura

ted

fat

tosa

tura

ted

fat

ratio,ce

real

fiber,

whole

grai

n,an

d

glyc

em

iclo

ad,ae

robic

exerc

ise,oth

er

PAof

atle

ast

modera

tein

tensi

ty,an

dT

Vvi

ewin

g

Age

,sm

okin

g,al

coholco

n-

sum

ption,co

ffee

inta

ke,

race

,fa

mily

his

tory

of

dia

-

bete

s,in

take

of

tota

l

energ

y,tr

ans

fat,

poly

un-

satu

rate

dfa

tto

satu

rate

d

fat

ratio,ce

real

fiber,

whole

grai

n,an

dgl

ycem

ic

load

,ae

robic

exerc

ise,

oth

er

PAof

atle

ast

mod-

era

tein

tensi

ty,an

dT

V

view

ing,

body

mas

sin

dex

The

United

Stat

es

(continued)

Saeidifard et al. 7

Tab

le1.

Continued

Firs

t

auth

or

Year

of

public

atio

n

Study

desi

gnN

Mean

follo

w-u

p

(year

s)

Sett

ing

(PIC

O)

(pat

ient,

inte

rvention/e

xposu

re,

com

par

ison,outc

om

e)

Fact

ors

adju

sted

for

Loca

tion

of

the

study

Exclu

sio

n:excl

uded

those

men

who

report

ed

ahis

tory

of

dia

bete

s,ca

nce

r,m

yoca

rdia

lin

farc

tion

angi

na,

coro

nar

y

arte

rybyp

ass

graf

t,oth

er

hear

tco

nditio

ns,

stro

ke,or

pulm

onar

yem

bolis

mon

the

bas

elin

equest

ionnai

re

(1986)

and

in1988,an

d1990.

Har

dee

26

2014

Cohort

2863

7.3

Part

icip

an

ts:ca

nce

rsu

rviv

ors

aged

18–81

year

s,both

mal

ean

dfe

mal

e,

who

rece

ived

apre

ventive

medic

al

exam

inat

ion

while

enro

lled

inth

eA

ero

bic

sC

ente

r

Longi

tudin

alSt

udy

inD

alla

s,Te

xas

Exp

osu

re:�

1se

ssio

nofm

usc

le-s

trengt

henin

gac

tivi

ties

at

bas

elin

ew

hic

hw

asas

sess

ed

by

self-

report

on

the

med-

ical

his

tory

quest

ionnai

re.Par

tici

pan

tsw

ere

aske

dto

pro

vide

yes/

no

answ

ers

toth

efo

llow

ing

quest

ions:

1).

‘‘Are

you

curr

ently

invo

lved

ina

musc

le-s

trengt

henin

g

pro

gram

?’’2

).‘‘C

anyo

usp

eci

fyth

em

usc

le-s

trengt

henin

g

activi

tyas

‘Cal

isth

enic

s’,‘F

ree

Weig

hts

’,‘W

eig

ht

Tra

inin

g

Mac

hin

es’

,or

‘Oth

er’

?’’3

).‘‘H

ow

man

yday

sper

week

do

you

do

these

exerc

ises?

’’T

hose

that

resp

onded

‘‘Yes’

’to

free

weig

hts

or

weig

ht

trai

nin

gan

dhad

exerc

ised

atle

ast

one

day

per

week

were

clas

sifie

das

posi

tive

for

musc

le-

stre

ngt

henin

gac

tivi

ty

Co

mp

ari

son

:no

musc

lest

rengt

henin

gac

tivi

ties

inth

e

pas

t30

day

s

Ou

tco

mes:

all-ca

use

and

card

iova

scula

rm

ort

ality

adju

sted

by

age,ge

nder,

body

mas

sin

dex,cu

rrent

smokin

g,heav

y

dri

nkin

g,hy

pert

ensi

on,dia

bete

s,hy

perc

hole

stero

lem

ia,

and

par

enta

lhis

tory

of

cance

r

Exclu

sio

n:Par

tici

pan

tsw

ere

excl

uded

from

the

final

ana-

lysi

sif

they

were

underw

eig

ht

(body

mas

sin

dex<

18.5

);

report

ed

myo

card

ialin

farc

tion

or

stro

ke;die

dduri

ng

first

year

offo

llow

-up;or

had

mis

sing

dat

aon

resi

stan

ce

exerc

ise

or

PA

Age

,ge

nder,

exam

inat

ion

year

,body

mas

sin

dex,

curr

ent

smokin

g,heav

y

dri

nkin

g,hy

pert

ensi

on,

dia

bete

s,hy

perc

hole

ster-

ole

mia

,an

dpar

enta

lhis

-

tory

ofca

nce

r,le

isure

-tim

e

aero

bic

phy

sica

lac

tivi

ty,

resi

stan

ceexerc

ise

The

United

Stat

es

(continued)


Tab

le1.

Continued

Firs

t

auth

or

Year

of

public

atio

n

Study

desi

gnN

Mean

follo

w-u

p

(year

s)

Sett

ing

(PIC

O)

(pat

ient,

inte

rvention/e

xposu

re,

com

par

ison,outc

om

e)

Fact

ors

adju

sted

for

Loca

tion

of

the

study

Kam

ada2

32017

Cohort

28,8

79

12

Part

icip

an

ts:par

tici

pan

tsof

Wom

en’s

Heal

thSt

udy

(fem

ale)

who

were

free

of

card

iova

scula

rdis

eas

e,

dia

-

bete

sm

elli

tus,

and

cance

rw

ith

avera

gebas

elin

eag

eof

62.2

year

s

Exp

osu

re:m

usc

le-s

trengt

henin

gac

tivi

ties

atbas

elin

e.

A

stre

ngt

htr

ainin

gquest

ionnai

rew

asin

cluded:‘‘D

uri

ng

the

pas

tm

onth

,w

hat

was

your

appro

xim

ate

tim

eper

week

spent

ateac

hof

the

follo

win

gre

creat

ional

activ-

itie

s?W

eig

ht

lifting/

stre

ngt

htr

ainin

g.’’

Co

mp

ari

son

:no

musc

lest

rengt

henin

gac

tivi

ties

inth

e

pas

t30

day

s

Ou

tco

mes:

all-ca

use

,ca

rdio

vasc

ula

r,an

dca

nce

rm

ort

ality

adju

sted

for

age

and

tria

lran

dom

izat

ion,r

ace,educa

tion,

post

menopau

salst

atus,

horm

one

use

,sm

okin

gst

atus,

par

enta

lhis

tory

of

myo

card

ialin

farc

tion

or

cance

r,

alco

holin

take

,energ

yin

take

,sa

tura

ted

fat

inta

ke,fib

er

inta

ke,fr

uit

and

vege

table

inta

ke,phy

sica

lexam

inat

ion

for

scre

enin

g,an

dtim

eper

week

spent

inae

robic

modera

teto

vigo

rous

PA(f

or

stre

ngt

htr

ainin

gan

dvi

ce

vers

a),body

mas

sin

dex

and

inci

dence

of

hypert

ensi

on,

hig

hch

ole

stero

l,ca

rdio

vasc

ula

rdis

eas

es,

dia

bete

sm

elli

-

tus,

and

cance

rbefo

rean

dduri

ng

follo

w-u

p

Exclu

sio

n:w

eexcl

uded

wom

en

with

mis

sing

info

rmat

ion

on

PAth

en,an

dw

om

en

dia

gnose

das

hav

ing

CV

D

(myo

card

ialin

farc

tion,s

troke

,perc

uta

neous

tran

slum

inal

coro

nar

yan

giopla

sty,

or

coro

nar

yar

tery

byp

ass

graf

t-

ing)

,ca

nce

r,or

dia

bete

sm

elli

tus

befo

reth

e96-m

onth

quest

ionnai

re

Age

,tr

ialra

ndom

izat

ion,

race

,educa

tion,post

me-

nopau

salst

atus,

horm

one

use

,sm

okin

gst

atus,

par

-

enta

lhis

tory

of

myo

card

ial

infa

rction

or

cance

r,al

co-

holin

take

,energ

yin

take

,

satu

rate

dfa

tin

take

,fib

er

inta

ke,fr

uit

and

vege

table

inta

ke,phy

sica

lexam

in-

atio

nfo

rsc

reenin

g,tim

e

per

week

spent

inae

robic

modera

teto

vigo

rous

PA,

body

mas

sin

dex,i

nci

dence

of

hypert

ensi

on,hig

h

chole

stero

l,ca

rdio

vasc

ula

r

dis

eas

es,

dia

bete

sm

elli

tus,

and

cance

rbefo

rean

d

duri

ng

follo

w-u

p

Kra

schnew

ski2

72016

Cohort

25,6

63

15

Part

icip

an

ts:in

div

idual

s�

65

year

s,both

men

and

wom

en,fr

om

the

1997–2001

NH

IS

Exp

osu

re:m

usc

le-s

trengt

henin

gac

tivi

ties

atbas

elin

eth

at

was

asse

ssed

usi

ng

the

follo

win

gquest

ion:‘‘H

ow

oft

en

do

you

do

leis

ure

-tim

ephy

sica

lac

tivi

ties

speci

fical

ly

desi

gned

tost

rengt

hen

your

musc

les,

such

aslif

ting

weig

ht

or

doin

gca

listh

enic

s?’’

Par

tici

pan

tre

sponse

s

incl

uded

both

the

num

ber

oftim

es

stre

ngt

htr

ainin

gw

as

perf

orm

ed

and

the

unit

of

tim

e(i.e

.‘‘p

er

week,’’

‘‘per

month

’’).

Age

,ge

nder,

race

/eth

nic

ity,

educa

tional

stat

us,

mar

ital

stat

us,

body

mas

sin

dex,

PA,al

coholuse

,sm

okin

g,

dia

bete

sm

elli

tus,

hyper-

tensi

on,co

ronar

yhear

t

dis

eas

e,

non-s

kin

cance

r

The

United

Stat

es

(continued)

Saeidifard et al. 9

Tab

le1.

Continued

Firs

t

auth

or

Year

of

public

atio

n

Study

desi

gnN

Mean

follo

w-u

p

(year

s)

Sett

ing

(PIC

O)

(pat

ient,

inte

rvention/e

xposu

re,

com

par

ison,outc

om

e)

Fact

ors

adju

sted

for

Loca

tion

of

the

study

Co

mp

ari

son

:not

meeting

the

guid

elin

efo

rm

usc

le

stre

ngt

henin

gac

tivi

ties

Ou

tco

mes:

all-ca

use

mort

ality

adju

sted

for

age,ge

nder,

eth

nic

ity,

educa

tional

stat

us,

mar

ital

stat

us,

body

mas

s

index,PA

,al

coholuse

,sm

okin

gst

atus,

dia

bete

s,hy

per-

tensi

on,co

ronar

yhear

tdis

eas

e,

non-s

kin

cance

rs

Lopri

nzi

14

2015

Cohort

12,3

21

4.8

Part

icip

an

ts:i

ndiv

idual

sw

ith

mean

age

of45.0

year

s,both

men

and

wom

en,fr

om

the

1999–2004

NH

AN

ES

Exp

osu

re:m

usc

le-s

trengt

henin

gac

tivi

ties

atbas

elin

e.

Indiv

idual

sse

lf-re

port

ed

their

invo

lvem

ent

inm

usc

le-

stre

ngt

henin

gac

tivi

ties

atth

ein

itia

lbas

elin

eas

sess

ment

by

resp

ondin

gto

two

quest

ions:

‘‘Ove

rth

epas

t30

day

s,

did

you

do

any

phy

sica

lac

tivi

ties

speci

fical

lydesi

gned

to

stre

ngt

hen

your

musc

les,

such

aslif

ting

weig

ht,

push

-ups

or

sit-

ups?

’’;an

dif

so‘‘O

ver

the

pas

t30

day

s,how

man

y

tim

es

did

you

do

these

activi

ties

desi

gned

tost

rengt

hen

your

musc

les,

such

aslif

ting

weig

hts

,push

-ups

or

sit-

ups?

’’as

the

num

ber

ofse

lf-re

port

ed

sess

ions

com

ple

ted

within

the

pas

t30

day

s

Co

mp

ari

son

:not

hav

ing

musc

lest

rengt

henin

gac

tivi

ties

in

the

pas

t30

day

s

Ou

tco

mes:

all-ca

use

mort

ality

and

card

iova

scula

rm

or-

talit

yad

just

ed

for

age,ge

nder,

race

–eth

nic

ity,

body

mas

s

index,an

dC

RP

Exclu

sio

n:excl

udin

gpar

tici

pan

tsw

ith

mis

sing

dat

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results of the study, only one cohort study looked at theassociation between resistance training and each non-fatal cardiovascular events also showing a lower risk ofMI among those performing resistance training.

The associations between resistance training andall-cause and also borderline association with cardio-vascular mortality could be explained by the multiplebeneficial changes that occur with resistance training,related to changes in body composition and glucosemetabolism and to the neuro-humoral system: resist-ance training decreases abdominal fat and specificallyvisceral fat, decreases the android-to-gynoid fat ratio,increases lean mass, prevents the development of sarco-penic obesity and slows muscle loss.5,11,30 This is key

because total body fat, and abdominal fat in particular,plays a pivotal role in facilitating the development ofmultiple kinds of chronic diseases such as obesity, type2 diabetes mellitus (T2DM) and cardiovascular condi-tions;8,11 all major contributors to a lower lifespan.On the other hand, obesity itself is associated withdysregulation of fatty acid metabolism resulting inaccumulation of lipid in the skeletal muscle cells,which increases insulin resistance.5 Resistance trainingalso decreases inflammatory products, likely as a reflec-tion of changes in body composition.5,31 Becauseinflammatory mediators increase the risk of CVD,metabolic syndrome, and T2DM, the effect of resist-ance training on reducing these mediators would at

Table 2. Risk of bias in different domainsa and overall risk of bias in different studies that were included in the systematic review and

meta-analysis of the association between resistance training and mortality (all-cause, cardiovascular, and cancer).

First author

Sequence

allocation

Allocation

concealment Blinding

Incomplete

outcome

data

Selective

outcome

reporting

Other sources

of bias

Overall

risk

of bias

Courneya21

Confounding Participants Classification

of interventions

Deviations

from intended

interventions

Missing

data

Measurement

of the outcome

Selection

of the

reported

result

Overall

riskb

of bias

Dankel 201616

Dankel 201720

Evenson22

Grøntved25

Hardee26

Kamada23

Kraschnewski27

Loprinzi14

Schoenborn15

Zhao24

aDifferent colors show different amount of risk of bias within different domains: green represents a low risk of bias, yellow represents an unclear risk of

bias or not enough information is provided in the study to make a judgment and red represents serious-to-critical risk of bias within each domain.bShows the overall risk of bias in different studies in the range of low to critical (low, moderate, serious, and critical risk of bias). Green shows a low

risk of bias and yellow shows a moderate risk of bias.


Courneya 2014Hardee 2014Loprinzi 2015Kamada 2017Dankel 2016Grøntved 2012

Grøntved 2012

Grøntved 2012

Total (95% CI)

Total (95% CI)

Heterogeneity: Tau2 = 0.01; Chi2 = 18.66, df = 5 (P = 0.002); I2 = 73%Test for overall effect: Z = 3.31 (P = 0.0009)

Kamada 2017

Dankel 2016

Subtotal (95% CI)




Courneya 2014

Kamada 2017

Dankel 2016

Grøntved 2012Kamada 2017

Dankel 2016

Subtotal (95% CI)

Subtotal (95% CI)

Heterogeneity: Tau2 = 0.02; Chi2 = 37.80, df = 9 (P < 0.0001); I2 = 76%Test for overall effect: Z = 2.21 (P = 0.03)Test for subgroup differences: Chi2 = 5.90, df = 2 (P = 0.05); I2 = 66.1%

Schoenborn 2011-ASchoenborn 2011-BZhao 2014

Total (95% CI)


Courneya 2014

Schoenborn 2011-ASchoenborn 2011-B

Kamada 2017Loprinzi 2015

Total (95% CI)

Heterogeneity: Tau2 = 0.02; Chi2 = 8.83, df = 4 (P = 0.07); I2 = 55%Test for overall effect: Z = 5.26 (P < 0.00001)

–0.5108 0.5119 1.8% 0.60 [0.22, 1.64]0.67 [0.45, 1.00]0.74 [0.51, 1.07]0.75 [0.69, 0.82]0.77 [0.60, 0.99]0.92 [0.87, 0.97]

8.9%9.8%

30.6%16.2%32.6%

0.20310.18990.04250.12730.0283

–0.4005–0.3011–0.2877–0.2614–0.0874

0.79 [0.69, 0.91]100.0%

–0.3285

–0.3285–0.1278

0.368 2.3%17.9%16.9%37.1%

0.04440.0298

0.72 [0.35, 1.48]0.88 [0.83, 0.93]0.72 [0.66, 0.79]0.79 [0.66, 0.95]

–0.5108 0.51190.1353

0.09680.057

–0.3147

–0.21070.0392

1.3%9.5%

15.9%12.5%39.2%

0.60 [0.22, 1.64]0.73 [0.56, 0.95]

0.81 [0.67, 0.98]1.04 [0.93, 1.16]

0.86 [0.69, 1.06]

5.3%11.6%6.8%

23.7%

–0.1508

0.09530.1044

0.1820.107

0.2189 0.86 [0.56, 1.32]

1.10 [0.77, 1.57]1.11 [0.90, 1.37]

1.07 [0.90, 1.26]

85.6%8.4%6.0% 0.87 [0.56, 1.35]

1.06 [0.73, 1.54]1.00 [0.89, 1.12]

–0.13930.0583

0.05950.19030.2248

0

100.0% 1.00 [0.89, 1.11]

100.0% 0.88 [0.78, 0.98]

5.6% 0.61 [0.28, 1.29]0.63 [0.46, 0.86]0.35 [0.17, 0.72]0.54 [0.48, 0.61]0.73 [0.60, 0.89]

20.2%6.1%

37.9%30.2%

–0.5014 0.38640.16050.36840.06010.1001

–0.462–1.0498–0.6162–0.3147

0.60 [0.49, 0.72]100.0%

2.1.3 2–5 resistance vs no-exercise

2.1.2 > 0–2 resistance vs no-exercise

2.1.4 ≥ 5 sessions of resistance vs no-exercise

Study or subgroup log[Hazard ratio] SE Weight IV, random, 95% CIHazard ratio

IV, random, 95% CIHazard ratio





Study or subgroup

(a)

(b)

(c)

(d)

log[Hazard ratio] SE Weight IV, random, 95% CIHazard ratio


0.1 0.2 0.5 1 2 5 10Resistance No exercise

0.2 0.5 1 2 5Resistance No exercise

0.01 0.1 1 10 100Resistance ≥ 2/W Resistance <2/W

0.01 0.1 1 10 100Resistance + aerobic No exercise

Figure 2. Meta-analysis of the association between resistance training and all-cause mortality. (a) The association between� 1

sessions of resistance training in the last 30 days versus performing no exercise and all-cause mortality. (b) Subgroup analysis based on

the association between different doses of resistance training and all-cause mortality. (c) Difference between the association of �2 and

<2 sessions of resistance training per week with all-cause mortality. (d) The association of the combination of resistance training and

aerobic exercise versus no-exercise with all-cause mortality. Squares show the weight given to each study in the analysis; larger

squares represent bigger weights. Diamonds denote pooled effect size. Vertical lines represent no effect.

SE: standard error; IV: inverse variance; CI: confidence interval


Grøntved 2012

Loprinzi 2015Kamada 2017

Dankel 2016

(a)

(b)

(c)

(b)


Dankel 2016

Total (95% CI)

Total (95% CI)

Total (95% CI)

Total (95% CI)

Subtotal (95% CI)


Dankel 2016

Subtotal (95% CI)

Kraschnewski 2016Zhao 2014







Test for subgroup differences: Chi2 = 0.02, df = 1 (P = 0.89); I2 = 0%

2.2.2 ≥ 2 resistance vs no-exercise

Loprinzi 2015Kamada 2017


IV, Random, 95% CIHazard ratio






IV, Random, 95% CIHazard ratio

–0.1199

0.6471 0.50490.06010.1339

–0.1054–0.4308

–0.4005

–0.1278

–0.5621–1.0498

0.27650.2142

0.07820.2277

89.4%10.6%

43.6%56.4%

100.0%

100.0%

0.88 [0.75, 1.03]

0.57 [0.33, 0.98]0.35 [0.23, 0.53]

0.43 [0.27, 0.70]

1.00 [0.64, 1.56]

0.89 [0.77, 1.03]

0

0.27610.1013

0.275–0.32850

0.40630.04690.12160.2244

5.7%48.4%30.7%15.1%

3.0%33.0%21.0%56.9%

8.5%

8.5%26.1%

43.1%

100.0%

100.0%

0.89 [0.40,1.97]0.91 [0.83,1.00]0.66 [0.52,0.84]0.95 [0.61,1.47]

1.91 [0.71, 5.14]0.90 [0.80, 1.01]0.65 [0.50, 0.85]0.85 [0.61, 1.19]

0.67 [0.39, 1.15]1.00 [0.82, 1.22]0.72 [0.42, 1.23]0.87 [0.67, 1.13]

0.85 [0.71, 1.01]

0.83 [0.68,1.01]

–0.0943–0.4155–0.0545




0.01 0.1 1 10 100Resistance ≥2 Resistance <2

2.2.1 >0–2 sessions of resistance vs no-exercise

Figure 3. Meta-analysis of the association between resistance training and cardiovascular mortality. (a) The association between� 1

sessions of resistance training in the last 30 days versus performing no exercise and cardiovascular mortality. (b) Subgroup analysis

based on the association between different doses of resistance training and cardiovascular mortality. (c) Difference between the

association of �2 and <2 sessions of resistance training per week with cardiovascular mortality. (d) The association of the com-

bination of resistance training and aerobic exercise versus no exercise with cardiovascular mortality. Squares show the weight given to

each study in the analysis; larger squares represent bigger weights. Diamonds denote pooled effect size. Vertical lines represent no

effect.



least partially explain the lower mortality in people per-forming resistance training. In addition, resistancetraining increases clearance of very low-density lipopro-tein-triglycerides from plasma as well as lipoproteinlipase gene expression and activity on the muscle cellmembranes, thereby increasing the catabolism andhydrolysis of very low-density lipoprotein-triglycer-ides.5 Lastly, resistance training improves mitochon-drial function in skeletal muscles and increases theexpression of glucose transporter type 4, the transloca-tor of glucose in the skeletal muscle, thus ultimatelyincreasing glucose uptake and glycogen synthesis inthis tissue. The overall outcome is decreased blood glu-cose and reduced cellular content of lipids, leading toimproved control of T2DM.5 The simultaneousincrease in lean mass due to resistance training alsoincreases basal metabolic rate,32 potentially contribut-ing to the prevention of obesity.

Evidence shows that performing four months ofresistance training or aerobic exercise leads to compar-able decreases in hepatic fat content, body fat mass,HBA1c levels, T2DM and non-alcoholic fatty liver

disease, while also increasing insulin sensitivity.33

In addition, a meta-analysis revealed that resistancetraining (dynamic or isometric) may significantlylower systolic and diastolic blood pressure.4 Alsoanother meta-analysis showed that resistance trainingincreases the lower and upper body strength and aer-obic fitness to a similar degree of aerobic exercise inpatients with coronary artery disease.7 All these physio-logic adaptations resulting from resistance training maylikely explain the inverse association between resistancetraining and mortality. On the other hand, Werneret al. found that, in contrast to endurance training,resistance training was not associated with telomeraseactivity and length, suggesting that resistance traininghad no anti-aging effect.34 This may explain why thepotentially beneficial effects of resistance training insurvival were modest when compared with endurancetraining.

In contrast to the improvements in overall mortalityand possible reduction in cardiovascular mortality, thisanalysis showed no significant association betweenresistance training and cancer mortality. Regardless of

Courneya 2014

Study or subgroup log[Hazard ratio] SE WeightHazard ratio


IV, random, 95% CI

–0.6931

0.01 0.1 1 10 100Resistance

04756 15.5%84.5%

0.50 [0.20, 1.27]0.88 [0.75, 1.02]

0.81 [0.54, 1.20]

0.0748

100.0%

–0.1278Kamada 2017

Total (95% CI)

Heterogeneity: Tau2 = 0.04 ; Chi2 = 1.38, df = 1 (P = 0.24); l2 = 27%Test for overall effect: Z = 1.05 (P = 0.29)

No exercise

Dankel 2017



IV, random, 95% CI

0.01 0.1 1 10 100Resistance ≥2 Resistance <2

0.86 [0.72, 1.04]100.0%

–0.0834 0.3592 6.7%93.3%

0.92 [0.46, 1.86]0.86 [0.71, 1.04]0.0964–0.1508Kraschnewski 2016

Total (95% CI)


Courneya 2014



IV, random, 95% CI


0.90 [0.75, 1.08]100.0%

–0.4943 0.3973 5.4%94.6%

0.61 [0.28, 1.33]0.92 [0.78, 1.09]0.0842–0.0834Kamada 2017

Total (95% CI)


(a)

(b)

(c)

Figure 4. Meta-analysis of the association between resistance training and cancer mortality. (a) The association between� 1 ses-

sions of resistance training per week versus performing no exercise and cancer mortality. (b) Difference between the association of

�2 and <2 sessions of resistance training per week with cancer mortality. (c) The association of the combination of resistance training

and aerobic exercise versus no-exercise with cancer mortality. Squares show the weight given to each study in the analysis; larger

squares represent bigger weights. Diamonds denote pooled effect size. Vertical lines represent no effect.



its association with mortality, resistance training islikely to be particularly important for cancer patients,as it helps to improve their muscle strength and specif-ically retains lean body mass.35,36 This may help to pro-tect patients from the adverse musculoskeletal effects ofcancer treatments such as chemotherapy, as well asincreasing quality of life and functional capacity com-pared with patients that do not participate in resistancetraining.21,37,38

Besides the overall association between resistancetraining and cardiovascular outcomes, a key questionin the association between resistance training and car-diovascular outcomes is how much resistance training isassociated with maximal health benefits. The results ofthis study suggested a ‘‘U-shape’’ dose–response rela-tionship between resistance training and all-cause andcardiovascular mortality, which reflects the results ofsome of the included studies.16,23 Similarly, studies test-ing the association of resistance training with glycemiccontrol in T2DM patients showed a non-linear rela-tionship between repetition and intensity of resistancetraining and HbA1c levels.39,40 One potential explan-ation for the non-linear association between resistancetraining and mortality could be related to the possibleadverse effects of high-intensity resistance training,which may significantly affect heart rate, increaseblood pressure and lead to adverse events.41,42 Alsohigh-intensity resistance training has been associatedwith increased arterial stiffness via increasing sympa-thetic nervous system activity which contributes tochronic restraint on the arterial wall.43 The accentuatedValsalva maneuver occurring during resistance trainingmay result in some changes to heart rhythm such asbradycardia or atrial ectopy: a rapid fall in blood pres-sure after maximum workload can cause syncope evenin healthy adults.44 Finally, people performing a highvolume of resistance training may be more likely to useanabolic–androgenic steroids or supplements with sub-stances that could adversely affect their health.45 Someof our analysis suggest that the optimal health benefitsof resistance training are most likely obtained by 1–2sessions per week and avoiding high-intensity low-repe-tition type activities. However, it is important to recog-nize that the current evidence is not enough to concludethat the relationship between resistance training andsurvival has a U-shape curve.

As expected, the association between the combin-ation of the resistance and aerobic training withall-cause and cardiovascular mortality was greaterthan the association of each kind of exercises alonewith all-cause mortality. This confirms the results ofthe individual studies in this regard.14,15,21,23

To the best of our knowledge, this is the first system-atic review and meta-analysis assessing the associationbetween resistance training and total mortality and

major cardiovascular outcomes, with over 370,000participants and around nine years of follow-up.Additionally, the included studies evaluated the associ-ation exclusively between resistance training and mor-tality, adjusting for different types of exercise andfor cardiovascular risk factors, thereby increasing thevalidity of the results. This study also pooled data onthe association between the combination of resistancetraining and aerobic exercise with mortality fromdifferent causes; although the direction of the resultwas not surprising, it can be used as objective evidencesupporting current guidelines.46

This study had several limitations. Most of theincluded studies were observational studies and theonly included randomized clinical trial was on patientswith breast cancer. The observational nature of most ofthe studies is a major limitation, a limitation sharedwith the level of evidence testing the effect of aerobicexercise on major cardiovascular outcomes and mortal-ity. This raises concerns about potential confoundersnot accounted for in the multivariate analyses of eachstudy. It is possible that unaccounted confounders suchdiet, medical conditions, use of medications or anabolicsteroids may have affected the results. Most partici-pants in the primary studies represented the generalpopulation and therefore the generalizability of theresults to cardiac patients could be questionable.Studies performed in cardiac patients are needed toprove the safety and benefit of resistance trainingamong those with cardiovascular diseases. The defin-ition of resistance training between studies was hetero-geneous, underscoring the complexity of measuringresistance training dose according to type of resistancetraining, repetition, intensity, resting time and whethermachines, free weights or no equipment were used. Theexposure to resistance training was self-reported andmeasured using questionnaires. Resistance trainingwas assessed at a single time, with no informationabout initiation or changes in frequency or durationof resistance training over time, limiting the validityof the data. Furthermore, heterogeneity was high insome analyses, likely reflecting differences in the typeof resistance training or in the populations studied.Unfortunately, the differences in type and dose ofresistance training across studies could not be accur-ately determined, preventing a subgroup analysis toprove this hypothesis. There was no study that directlycompared resistance training with aerobic exercise andtheir association with mortality from different causes,limiting our ability to make conclusions about the bene-fit of performing resistance training instead of aerobicexercise. The results also highlight the limited dataassessing the association between resistance trainingand non-fatal cardiovascular outcomes such as MI,sudden death, and stroke. It also remains unclear how


resistance training and aerobic exercise compare, andwhat is the optimal dose of resistance training, aloneand in combination with aerobic exercise, for healthbenefits in both the general population and specificpatient groups. The limited number of eligible studieswas also a limitation, although the number of the studyparticipants was considerably large. Further studiestesting the association between resistance training andmajor cardiovascular outcomes will help to elucidatethe role of resistance training in cardiovascular diseaseprevention as well as the optimal dose and modality ofresistance training to yield any benefit.

Conclusion

There is a significant association between resistancetraining and lower all-cause mortality and a borderlineassociation with cardiovascular mortality. There areinsufficient data to determine the potential beneficialeffect of resistance training on non-fatal events or theeffect of substituting aerobic exercise with resistancetraining.

Author contribution

FS, JRMI, CPW, TPO, VKS, ARB, LJP, MV and FLJ con-

tributed to the conception or design of the work. FS and FLJcontributed to the acquisition, analysis, and interpretation ofdata, JRMI contributed to the acquisition and analysis,

CPW, TPO, VKS and ARB contributed to the interpretationand LJP contributed to the acquisition of the data for thework. FS, JRMI, CPW, TPO, VKS, ARB, LJP, MV and

FLJ drafted the manuscript. FS, JRMI, CPW, TPO, VKS,ARB, LJP, MV and FLJ critically revised the manuscript. Allgave final approval and agree to be accountable for all aspects

of work ensuring integrity and accuracy.

Acknowledgements

We thank Dr. Paul D Loprinzi, Associate Professor of theUniversity of Mississippi, Dr. Frank B Hu, Professor of

Harvard T.H. Chan School of Public Health, and Dr.Anders Grøntved, Associate Professor of University ofSouthern Denmark, for providing additional data, and alsoDr. Lucy Robinson from InsightEditingLondon for editing

the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest withrespect to the research, authorship, and/or publication of this

article.

Funding

The author(s) disclosed receipt of the following financial sup-port for the research, authorship, and/or publication of this

article: This work was supported by the Project FNUSA-ICRC (No. CZ.1.05/1.1.00/02.0123), by project no. LQ1605from the National Program of Sustainability II (MEYS CR),

by the project ICRC-ERA-Human Bridge (No. 316345),funded by the 7th Framework Program of the EuropeanUnion, NIH/NHLBI grant (No. HL-126638 to TPO) and

National Institute of Health (NIH) grants (R01HL-134808and R01HL-114024 to V.K.S). The content is solely theresponsibility of the authors and does not necessarily repre-sent the official views of the NIH.

References

1. Biswas A, Oh PI, Faulkner GE, et al. Sedentary time and

its association with risk for disease incidence, mortality,

and hospitalization in adults: A systematic review and

meta-analysis. Ann Intern Med 2015; 162: 123–132.2. Kim Y, Wilkens LR, Park S-Y, et al. Association

between various sedentary behaviours and all-cause, car-

diovascular disease and cancer mortality: The

Multiethnic Cohort Study. Int J Epidemiol 2013; 42:

1040–1056.

3. Hupin D, Roche F, Gremeaux V, et al. Even a low-dose

of moderate-to-vigorous physical activity reduces mortal-

ity by 22% in adults aged �60 years: A systematic review

and meta-analysis. Br J Sports Med 2015; 49: 1262–1267.

4. Cornelissen VA, Fagard RH, Coeckelberghs E, et al.

Impact of resistance training on blood pressure and

other cardiovascular risk factors: A meta-analysis of ran-

domized, controlled trials. Hypertension 2011; 58:

950–958.5. Strasser B and Pesta D. Resistance training for diabetes

prevention and therapy: Experimental findings and

molecular mechanisms. Biomed Res Int 2013; 2013:

805217.6. Pressler A, Forschner L, Hummel J, et al. Long-term

effect of exercise training in patients after transcatheter

aortic valve implantation: Follow-up of the SPORT:

TAVI randomised pilot study. Eur J Prev Cardiol 2018;

25: 794–801.7. Hollings M, Mavros Y, Freeston J, et al. The effect of

progressive resistance training on aerobic fitness and

strength in adults with coronary heart disease: A system-

atic review and meta-analysis of randomised controlled

trials. Eur J Prev Cardiol 2017; 24: 1242–1259.8. Aune D, Norat T, Leitzmann M, et al. Physical activity

and the risk of type 2 diabetes: A systematic review and

dose–response meta-analysis. Eur J Epidemiol 2015; 30:

529–542.9. Bouaziz W, Vogel T, Schmitt E, et al. Health benefits of

aerobic training programs in adults aged 70 or over: A

systematic review. Presse Med 2017; 46: 794.10. Camilo Turi B, Luiz Monteiro H, Araujo Fernandes R,

et al. The impact of physical activity on mitigation of

health care costs related to diabetes mellitus: Findings

from developed and developing settings. Curr Diabetes

Rev 2016; 12: 307–311.

11. Hills AP, Shultz S, Soares MJ, et al. Resistance training

for obese, type 2 diabetic adults: A review of the evidence.

Obes Rev 2010; 11: 740–749.

12. Amusa LO and Obajuluwa VA. Static versus dynamic

training programs for muscular strength using the knee


extensors in healthy young men. J Orthop Sports Phys

Ther 1986; 8: 243–247.

13. Olver TD and Laughlin MH. Endurance, interval sprint,

and resistance exercise training: Impact on microvascular

dysfunction in type 2 diabetes. Am J Physiol Heart Circ

Physiol 2016; 310: H337–H350.14. Loprinzi PD and Davis RE. Effects of individual, com-

bined, and isolated physical activity behaviors on all-

cause mortality and CVD-specific mortality: Prospective

cohort study among U.S. adults. Physiol Behav 2015; 151:

355–359.15. Schoenborn CA and Stommel M. Adherence to the 2008

adult physical activity guidelines and mortality risk. Am J

Prev Med 2011; 40: 514–521.16. Dankel SJ, Loenneke JP and Loprinzi PD. Dose-depen-

dent association between muscle-strengthening activities

and all-cause mortality: Prospective cohort study among

a national sample of adults in the USA. Arch Cardiovasc

Dis 2016; 109: 626–633.17. Rao G, Lopez-Jimenez F, Boyd J, et al. Methodological

standards for meta-analyses and qualitative systematic

reviews of cardiac prevention and treatment studies: A

scientific statement from the American Heart

Association. Circulation 2017; 136: e172–e194.18. Sterne JA, Hernan MA, Reeves BC, et al. ROBINS-I: A

tool for assessing risk of bias in non-randomised studies

of interventions. BMJ 2016; 355: i4919.

19. Higgins J, Sterne J, Savovic J, et al. A revised tool for

assessing risk of bias in randomized trials. Cochrane

Database Syst Rev 2016; 10(Suppl 1): 29–31.20. Dankel SJ, Loenneke JP and Loprinzi PD. Cancer-speci-

fic mortality relative to engagement in muscle-strengthen-

ing activities and lower extremity strength. J Phys Act

Health 2017; 20: 1–6.21. Courneya KS, Segal RJ, McKenzie DC, et al. Effects of

exercise during adjuvant chemotherapy on breast cancer

outcomes. Med Sci Sports Exerc 2014; 46: 1744–1751.

22. Evenson KR, Wen F and Herring AH. Associations of

accelerometry-assessed and self-reported physical activity

and sedentary behavior with all-cause and cardiovascular

mortality among US adults. Am J Epidemiol 2016; 184:

621–632.

23. Kamada M, Shiroma EJ, Buring JE, et al. Strength train-

ing and all-cause, cardiovascular disease, and cancer mor-

tality in older women: A cohort study. J Am Heart Assoc

2017; 6: e007677.24. Zhao G, Li C, Ford ES, et al. Leisure-time aerobic phys-

ical activity, muscle-strengthening activity and mortality

risks among US adults: The NHANES linked mortality

study. Br J Sports Med 2013; 48: 244–1449.

25. Grøntved A, Rimm EB, Willett WC, et al. A prospective

study of weight training and risk of type 2 diabetes mel-

litus in men. Arch Intern Med 2012; 172: 1306–1312.26. Hardee JP, Porter RR, Sui X, et al. The role of resistance

exercise on all-cause mortality in cancer survivors: 1982

Board# 268 May 29, 2. Med Sci Sports Exerc 2014; 46:

544.

27. Kraschnewski JL, Sciamanna CN, Poger JM, et al. Is

strength training associated with mortality benefits?

A 15year cohort study of US older adults. Prev Med

2016; 87: 121–127.

28. Tanasescu M, Leitzmann MF, Rimm EB, et al. Exercise

type and intensity in relation to coronary heart disease in

men. JAMA 2002; 288: 1994–2000.29. Shiroma EJ, Cook NR, Manson JE, et al. Strength train-

ing and the risk of type 2 diabetes and cardiovascular

disease. Med Sci Sports Exerc 2017; 49: 40.30. Treuth MS, Hunter GR, Kekes-Szabo T, et al. Reduction

in intra-abdominal adipose tissue after strength training

in older women. J Appl Physiol 1995; 78: 1425–1431.

31. Strasser B, Arvandi M and Siebert U. Resistance train-

ing, visceral obesity and inflammatory response: A review

of the evidence. Obes Rev 2012; 13: 578–591.32. Hunter GR, Wetzstein CJ, Fields DA, et al. Resistance

training increases total energy expenditure and free-living

physical activity in older adults. J Appl Physiol 2000; 89:

977–984.33. Bacchi E, Negri C, Targher G, et al. Both resistance

training and aerobic training reduce hepatic fat content

in type 2 diabetic subjects with nonalcoholic fatty liver

disease (the RAED2 Randomized Trial). Hepatology

2013; 58: 1287–1295.34. Werner CM, Hecksteden A, Morsch A, et al. Differential

effects of endurance, interval, and resistance training on

telomerase activity and telomere length in a randomized,

controlled study. Eur Heart J 2018; 40: 34–46.35. Padilha CS, Marinello PC, Galvao DA, et al. Evaluation

of resistance training to improve muscular strength and

body composition in cancer patients undergoing neoad-

juvant and adjuvant therapy: A meta-analysis. J Cancer

Surviv 2017; 11: 339–349.36. Van Moll CC, Schep G, Vreugdenhil A, et al. The effect

of training during treatment with chemotherapy on

muscle strength and endurance capacity: A systematic

review. Acta Oncol 2016; 55: 539–546.

37. Steindorf K, Schmidt M, Klassen O, et al. Randomized,

controlled trial of resistance training in breast cancer

patients receiving adjuvant radiotherapy: Results on

cancer-related fatigue and quality of life. Ann Oncol

2014; 25: 2237–2243.38. Norris MK, Bell G, North S, et al. Effects of resistance

training frequency on physical functioning and quality of

life in prostate cancer survivors: A pilot randomized con-

trolled trial. Prostate Cancer Prostatic Dis 2015; 18:

281–287.39. Yang P, Swardfager W, Fernandes D, et al. Finding the

optimal volume and intensity of resistance training exer-

cise for type 2 diabetes: The FORTE study, a randomized

trial. Diabetes Res Clin Pract 2017; 130: 98–107.40. Taylor JD, Fletcher JP, Mathis RA, et al. Effects of

moderate-versus high-intensity exercise training on phys-

ical fitness and physical function in people with type 2

diabetes: A randomized clinical trial. Phys Ther 2014; 94:

1720–1730.41. Lamotte M, Niset G and van de Borne P. The effect of

different intensity modalities of resistance training on

beat-to-beat blood pressure in cardiac patients. Eur J

Cardiovasc Prev Rehabil 2005; 12: 12–17.


42. MacDougall J, Tuxen D, Sale D, et al. Arterial bloodpressure response to heavy resistance exercise. J ApplPhysiol 1985; 58: 785–790.

43. Miyachi M. Effects of resistance training on arterial stiff-ness: A meta-analysis. Br J Sports Med 2013; 47: 393–396.

44. Bjarnason-Wehrens B, Mayer-Berger W, Meister E, et al.Recommendations for resistance exercise in cardiac

rehabilitation. Recommendations of the GermanFederation for Cardiovascular Prevention and

Rehabilitation. Eur J Cardiovasc Prev Rehabil 2004; 11:352–361.

45. Van Amsterdam J, Opperhuizen A and Hartgens F.

Adverse health effects of anabolic–androgenic steroids.Regul Toxicol Pharmacol 2010; 57: 117–123.

46. U.S. Department of Health and Human Services.Physical Activity Guidelines for Americans, 2nd edition.

Washington, DC: U.S. https://health.gov/paguidelines/second-edition/report/ (2018, accessed 8 May 2019).


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